Provider Demographics
NPI:1508554114
Name:RADIANT 828, LLC
Entity Type:Organization
Organization Name:RADIANT 828, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STORMEY
Authorized Official - Middle Name:
Authorized Official - Last Name:NIELSEN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:385-347-0904
Mailing Address - Street 1:5801 S FASHION BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-6162
Mailing Address - Country:US
Mailing Address - Phone:385-347-0904
Mailing Address - Fax:
Practice Address - Street 1:5801 S FASHION BLVD STE 200
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-6162
Practice Address - Country:US
Practice Address - Phone:385-347-0904
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-01
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)